Nursing Elites

1. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, 'Take me home. I want my Mommy.' Which response is best for the LPN/LVN to provide?

• A. Orient the client to the time, place, and person.
• B. Tell the client that the nurse is there and will help her.
• C. Remind the client that her mother is no longer living.
• D. Explain the seriousness of her injury and need for hospitalization.

Correct answer: B

Rationale: The correct answer is to tell the client that the nurse is there and will help her. Providing reassurance and presence is more therapeutic in dealing with a client who has advanced dementia and is expressing a desire to go home and be with her mother. Option A might not be effective as continuously orienting the client may not alleviate her distress. Option C, reminding the client that her mother is no longer living, can be distressing and may not be appropriate in this situation. Option D, explaining the seriousness of the injury and need for hospitalization, is not the best response as it does not address the client's emotional needs at that moment.

2. A client with schizophrenia is experiencing delusions. What is the most appropriate nursing intervention?

• A. Encourage the client to explore the delusions in depth.
• B. Tell the client that the delusions are not real.
• C. Explore the underlying meaning of the delusions.
• D. Distract the client from the delusions and focus on reality.

Correct answer: D

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing delusions is to distract the client from the delusions and focus on reality. Encouraging the client to explore the delusions in depth (Choice A) may worsen the delusions. Telling the client that the delusions are not real (Choice B) can lead to confrontation and disbelief. Exploring the underlying meaning of the delusions (Choice C) may not be effective during acute episodes of delusions; hence, distracting the client and refocusing on reality is the most suitable intervention.

3. A client with bipolar disorder, manic phase, is admitted to the psychiatric unit. Which meal is most appropriate for this client?

• A. Spaghetti and meatballs
• B. Chicken salad sandwich
• C. Steak and potatoes
• D. Hamburger and fries

Correct answer: B

Rationale: A chicken salad sandwich (B) is the most appropriate choice as it is easy to eat on the go, which is important for a client in the manic phase who may have difficulty sitting still for a meal. Spaghetti and meatballs (A) and steak and potatoes (C) require more time and effort to eat, which may be challenging for a client experiencing mania. While hamburger and fries (D) could be an option, a chicken salad sandwich is a healthier and more manageable choice, considering the client's potential hyperactive state.

4. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?

• A. Sublimation.
• B. Identification.
• C. Introjection.
• D. Repression.

Correct answer: B

Rationale: Identification is the correct answer. It is a defense mechanism where an individual unconsciously models themselves after someone they admire or feel close to. In this scenario, the client is imitating the nurse's mannerisms, indicating identification. Sublimation involves channeling unacceptable impulses into socially acceptable activities. Introjection is the internalization of external attitudes or voices, while repression involves suppressing unwanted thoughts or desires.

5. A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?

• A. Attempt to ask the client simple questions.
• B. Postpone the client interview until the next day.
• C. Ask another nurse to talk with the client.
• D. Document the client's paranoid behavior.

Correct answer: A

Rationale: When a client is guarded, suspicious, and resistant to talking, it is important for the nurse to attempt to ask the client simple questions. Simple questions can help build rapport, establish trust, and create a non-threatening environment. This approach may ease the client into more detailed discussions while reducing feelings of suspicion. Postponing the interview may increase the client's anxiety and distrust, while asking another nurse to talk with the client may disrupt continuity of care and the establishment of a therapeutic relationship. Documenting the client's behavior is important for the client's medical record, but it should not be the first action taken in this situation.

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